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病历摘要 例1女,40岁。10天前突觉视物双影,4天前左眶疼痛而入院。无高血压史。查体:BP13/8kPa,神清。左眼:上睑下垂,眼裂小,上下视及内收障碍,瞳孔0.4cm,对光反应迟钝,外展正常。右眼:瞳孔0.2cm,对光反应正常。余神经系统(一)。CT示:中脑偏左见3.0×2.3×2.0cm~3高密度灶,CT值为39～5.9H_u,提示左侧中脑出血。入院后4天有一过性右上肢乏力及麻木。经脱水、神经营养药等治疗病情好转出院。2月后随访,除左眼轻度内收障碍外,余正常。
Case history summary 1 female, 40 years old. Ten days ago, visual acuity double shadow, 4 days ago left orbital pain and admission. No history of hypertension. Physical examination: BP13 / 8kPa, God clear. Left eye: ptosis, small oculus, up and down and adduction disorders, pupil 0.4cm, unresponsive to light, normal outreach. Right eye: pupil 0.2cm, normal reaction to light. I nervous system (a). CT showed: the left side of the midbrain see 3.0 × 2.3 × 2.0cm ~ 3 high-density lesions, CT value of 39 ~ 5.9H_u, suggesting that the left middle cerebral hemorrhage. 4 days after admission, a transient right upper limb fatigue and numbness. After dehydration, neurotrophic drugs and other treatment improved condition and discharged. Follow-up after 2 months, except for the left eye mild adduction disorder, I normally.